Benjamin Compton

CONFIDENTIAL 

Mr Philip Spinney 
HM Senior Coroner 
County Hall  
Topsham Road  
Exeter  
EX24QD  

Sent via e-mail 

Dear Mr Spinney 

                                            Trust Headquarters 
                                            Wonford House 
                                            Dryden Road 
                                            Exeter 
                                            EX2 9AF 

                                           Tel: 01392 208683 

                                            Date: 07 May 2025. 

Re. Mr Benjamin Robert Compton – Regulation 28 report. 

I write in my capacity as Chief Nursing Officer and Allied Professions Lead at Devon Partnership 
NHS Trust (the Trust) in response to your regulation 28 report dated 19 March 2025.   

Can I first of all pass on my condolences to Mr Compton’s family and friends. 

In your report you  highlighted areas of concern to Devon Integrated Care Board, Director for 
Primary Care NHS Devon, and NHS England along with us Devon Partnership NHS Trust (DPT).  

In respect to the concerns pertinent to DPT I respond as below: 

MATTERS OF CONCERN are as follows: 

The evidence reveals that there was a gap in the provision of care for individuals suffering 
with  autism  and  in  crisis, which  remains the case  today  both  in  Devon and  nationally.  
Evidence was heard that a gap exists with autistic people in distress and or dysregulation 
with no treatable mental health condition and there is a grey area around treatment.  This 
is beyond the skills of social care providers. And unless the individual meets the criteria 
for treatment under the Mental Health Act there is very little support: 

At the time of, and during the period leading up to Mr Compton’s death, as you  highlight the 
Trust and wider Devon system did not have access to a specific autism crisis team.  This was, 
and remains, a known gap in commissioning across the country.  

  in  her  testimony  in  court,  the  Devon  Adult 
At  the  time,  as  described  by 
Autism Intervention Team (DAAIT), had recently been commissioned to provide a countywide 
service for autistic adults with the aim to: 

•  Prevent unnecessary hospital admission 
•  Reduce length of stay 
•  Prevent placement/accommodation breakdown including within family home 
•  Support the individual and their team(s)/supporters to better understand  where 

autism is impacting on the person’s stability, and the barriers to 
interventions/treatment options and solutions, where autism is the key or 
contributing factor to individuals needs/concerns. 

Chair: 

         Chief Executive:  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
  also explained, DAAIT at that time were in the developmental phase and 
As 
not yet operational. The team was not scheduled to  become operational (become open to 
referrals, commence clinical work) until April 2020. This timeframe was achieved.  

However, had DAAIT been operational at the time of Mr Compton’s distress there still 
would not have been a specific dedicated autism crisis pathway that he could access. 
The DAAIT service operates with a duty worker system 5 days per week, staffed by team 
members. Because of the low demand on duty in terms of volume of queries, and  DAAIT 
service not commissioned to provide an “urgent response”, there is a time frame for 
response of 48hrs, predominantly this accessed via email queries. This provision is 
noted in the service Standard Operating Procedure. If there was  a significant concern 
that there was an immediate threat to life then the staff member dealing with the query 
would contact the police via 999. 

DAAIT is a very small team, and as part of its commissioning it is explicitly not able to 
provide: 

•  A care coordination function, and as a result the expectation is that DAAIT staff 
will work as part of the overall health and/or social care network around the 
person at that time. Any work, regardless of tier, will be time  limited. 

•  An emergency or crisis response. 
•  Services/treatment which can be provided by mainstream services, with 

reasonable adjustments. 

Subsequent regional developments: 

Regionally the lack of specifically designed inpatient environments to best assesses/treat 
adults with a learning disability and/or who are autistic with co-morbid mental health 
issues was acknowledged by NHS England and led to a range of funding to build x2 ten 
bedded inpatient units for this cohort. Devon Partnership Trus t has been the lead 
provider for one of these (The Brook), which is currently under construction  in Dawlish, 
Devon, and is due to open summer 2025. The other unit (The Kingfisher) is being built in 
Bristol but is not due to open until later in 2026. 

As part of the regional development a Learning Disability/Autism Outreach team has 
been commissioned to sit alongside each unit as part of what is being seen as regional  a 
Learning Disability/Autism service. The LD/A outreach linked with The Brook, is due to 
become operational at a similar time to the unit opening. 

It is important to stress that the LD/A Outreach is not  commissioned to provide crisis 
support/intervention in the same way that mental health crisis/home treatment teams  are 
but will be able to work closely with these teams and other services, the patients network 
etc providing specific autism relevant advice/guidance and interventions.  

Benjamin was removed from his GP practice due to violent behaviour and 
allocated to the Special Allocation Scheme.  This scheme was not able to meet the 
needs of a patient such as Benjamin with a diagnosis of autism spectrum disorder. 

Devon Partnership NHS Trust are not able to comment on this specific question as it is a Primary 
Care/GP related one. 

Page 2 of 3 

         
 
 
 
 
 
 
 
 
 
         
 
 
 
 I trust the above responds clearly to your question. 

Yours sincerely 

Chief Nursing Officer and Allied Professionals Lead 

Page 3 of 3

NHS Devon  
Aperture House 
Pynes Hill 
Rydon Lane 
Exeter 
EX2 5AZ 
01392 205 205 

NHS Devon Response to Regulation 28 Report to Prevent Future Deaths 
To: HM Coroner Mr Spinney 
In the matter of: Benjamin Robert Compton 
Coroner’s Case Reference: 
Date of Regulation 28 Report: 19th March 2025 
Date of NHS Devon Response: 4th June 2025 

Dear Mr Spinney, 

NHS Devon acknowledges receipt of the Regulation 28 report following the inquest into 
the death of Benjamin Robert Compton. We would first like to extend our condolences to 
Benjamin’s family, friends, and all those who cared for and supported him. We recognise 
the impact of his death and the importance of the coroner's concerns in ensuring future 
improvements to the health and care system.  This letter sets out NHS Devon’s response 
to the matters of concern you have identified. 

Matters of Concern and Responses 

Concern 1: 
The evidence reveals that there was a gap in the provision of care for individuals suffering 
with autism and in crisis, that remains the case today both in Devon and 
nationally.  Evidence was heard that a gap exists with autistic people in distress and or 
dysregulation with no treatable mental health condition and there is a grey area around 
treatment.  This is beyond the skills of social care providers. And unless the individual 
meets the criteria for treatment under the Mental Health Act there is very little support. 

Consideration should be given to reviewing the process of supporting and providing 
interventions to those individuals suffering with autism and in crisis. 

Response: 
Devon ICB recognises the existing commissioning gap for individuals with autism who 
experience crisis. In response, significant work has been undertaken in 2023–2024 to 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 raise awareness and implement reasonable adjustments to better meet their mental health 
needs. 

In 2022, Devon received capital investment to develop a new community inpatient service 
dedicated to people with learning disabilities and autism requiring mental health treatment. 
This regional centre, one of two in the Southwest, aims to become a centre of excellence 
providing specialist expertise, training, and system-wide support. The first inpatient beds 
are scheduled to open in June 2025. 

Alongside this, an outreach and inreach service will be integrated into the pathway to 
prevent unnecessary admissions and ensure timely, appropriate care. 

Furthermore, the implementation of the Oliver McGowan mandatory training will enhance 
community skills and promote reasonable adjustments across services, ensuring that 
autistic individuals in crisis receive appropriate support. 

To review and improve current processes for crisis support, the Learning Disability and 
Neurodiversity commissioning team will conduct a comprehensive community delivery 
review in 2025/2026. This review will cover primary care, secondary care, social care, and 
acute services to optimise care pathways for this population. 

A full commissioning review and improvement plan will also be presented to the Devon 
ICB executive in the last quarter of this financial year. 

Concern 2: 
Benjamin was removed from his GP practice due to violent behaviour and allocated to the 
Special Allocation Scheme.  This scheme was not able to meet the needs of a patient such 
as Benjamin with a diagnosis of Autism Spectrum Disorder.  

Consideration should be given to ensuring that when patients are allocated to the GP 
Special Allocation Scheme they are properly assessed as being suitable for the scheme 
and receive the appropriate clinical care and treatment. 

Response: 
We have previously made improvements to processes and requirements in this scheme 
since this case. The changes include reviewing the process the practice has followed to 
ensure it meets all the requirements for allocation to the Special Allocation Scheme and 
where an appeal is made, the panel agenda has clear items to check/ensure the practice 
has followed the appropriate processes for assigning to the scheme. 

Regarding the application of our process in this case, we have also reflected previously on 
this case that a choice should have been given to whether the family wished for the appeal 
panel to take place, following this person's death, rather than ceasing all communication in 
an intended act of respect. 

Following receiving this Prevention of Future Deaths notice we have additionally 
considered what extra action can be taken to additionally strengthen arrangements. We 
have determined to make a modification to the Special Allocation Scheme Standard 
Operating Procedures (SOP) that specifically requires written confirmation from Practices 
that they considered all possible alternative approaches to providing primary medical 
services prior to making the placement. This change was enacted in May 2025. 

2 

 
 
 
 
 
 
 
 
 
 
 
 In summary the death of Benjamin highlights the need for continued improvement in how 
services respond to autistic individuals in crisis. Devon ICB is committed to taking forward 
the actions outlined above, strengthening our approach, and working with partners to 
ensure compassionate, appropriate, and timely support is available when it is most 
needed. 

Should any further information or clarification be required, we would be pleased to provide 
it. 

Yours sincerely, 

Primary Care Medical Director, NHS Devon  

3

Mr Philip Spinney 
HM Senior Coroner 
County of Devon, Plymouth and Torbay  
County Hall  
Topsham Road 
Exeter 
EX2 4QD  

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

14 May 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Benjamin Robert 
Compton who died on 1 February 2022  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  19 
March 2025 (concerning the death of Benjamin Robert Compton on 1 February 2022. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Benjamin’s family and loved ones. NHS England 
are  keen  to  assure  the  family  and  the  Coroner  that  the  concerns  raised  about 
Benjamin’s care have been listened to and reflected upon.  

Gap in the provision of care  

Your  Report  raises  concerns  over  a  gap  in  the  provision  of  care  nationally  for 
individuals  suffering  with  autism  and  in  mental  health  crisis.  It  is  for  NHS  Devon 
Integrated Care Board, who I note you have also sent your Report to, to respond to 
your concerns regarding provision of care within Devon.  

NHS England recognises the seriousness of the issues raised regarding the care of 
autistic individuals experiencing crisis, particularly where the threshold for detention 
under  the  Mental  Health  Act  is  not  met,  but  where  proactive,  multidisciplinary 
intervention is still clearly needed. NHS England remains committed to working with 
local systems to address such gaps and to reduce the risk of similar tragic outcomes. 

In December 2023, NHS England published Meeting the Needs of Autistic Adults in 
Mental  Health  Services,  which  provides  guidance  to  Integrated  Care  Boards  and 
health  providers  on  delivering  accessible,  autism-informed  care.  Key  areas  of 
relevance to your Report include: 

• 

Improving crisis pathways by supporting tailored, multidisciplinary input for 
autistic people, particularly where access to traditional mental health services 
may be limited. 

•  Strengthening the interface between primary care and specialist mental 
health services, ensuring autistic adults can access support for co-occurring 
mental health needs at any level of care. 

                                                                                                                       
 
 
 
 
 
 
  
 
 
  
 •  Embedding sensory-informed care, including environmental adaptations and 
the  use  of  health  passports,  to  improve  accessibility  and  safety  across  both 
urgent and planned care. 

•  Addressing  diagnostic  overshadowing,  where  a  person’s  autistic  traits, 
including communication style, behaviour, or presentation, are misattributed to 
an  existing  mental  health  or  neurodevelopmental  condition,  delaying 
appropriate assessment or support. 

•  Maintaining  access  to  timely  clinical  oversight  and  continuity  of  care, 

especially for autistic individuals in acute distress. 

In  addition,  NHS  England’s  Staying  Safe  from  Suicide  guidance  (April  2025) 
emphasises the importance of a whole-system approach to suicide prevention, which 
that  people 
includes  supporting  personalised  safety  planning  and  ensuring 
experiencing  distress,  regardless  of  diagnosis,  are  able 
timely, 
compassionate,  and  coordinated  care.  The  guidance  underscores  the  need  for 
services to work together to address gaps and transitions that may place individuals 
at heightened risk. 

to  access 

Special Allocation Scheme 

Your  Report  also  raises  a  concern  over  the  Special  Allocation  Scheme  (SAS)  and 
states  that  consideration  should  be  given  to  ensuring  that  patients  are  properly 
assessed as being suitable for the scheme before they are allocated, to ensure they 
get the appropriate care and treatment.  

GP contract regulations specify the grounds on which a contractor (i.e. a GP practice) 
may request that a person be removed from its list of patients with immediate effect. 
These are namely that: 

a)  the  person  has  committed  an  act  of  violence  against  any  of  the  persons 
specified [essentially any member of the practice, a visitor or other patients] or 
has behaved in such a way that any of those persons has feared for their safety. 

b)  the contractor has reported the incident to the police.  

The  regulations  do  not  include  a  list  of  objectively  defined  behaviours  or  medical 
conditions  which  are  excluded  from  referral;  this  is  in  recognition  of  the  complex 
interactions that can take place in healthcare settings and the importance of ensuring 
that practices can maintain a safe environment for their patients and their staff.   

In  practice,  this  means  there  is  a  balanced  need  for  ‘careful  considerations’  to  be 
undertaken.  On  the  one  hand,  by  the  provider,  prior  to  referring  a  patient  into  the 
scheme and, on the other hand, by providers of GP SAS services when accepting a 
patient on to the scheme. 

NHS England publishes national guidance to GP practices and commissioners on the 
implementation of, and commissioning and monitoring of, GP SAS services. This is 
contained  in  Chapter  7  of  NHS  England  »  Primary  medical  services  policy  and 
guidance manual (PGM). 

 
 The PGM was updated on 15 July 2024 to include the following key updates in the 
SAS section: 

a)  Remind GP practices of the need to undertake careful considerations prior to 
referring a patient into the scheme, having considered the patient’s protected 
characteristics, past medical history, learning disability and neurodiversity.  
b)  Implement a prompt to GP practices when completing the online referral on the 
need for careful consideration (Status: in the process of implementation). 
c)  An action request for commissioners to consider establishing and embedding 
initial appropriateness assessments into all commissioned SAS services. This 
would  be  subject  to  consideration  when  new  services  are  commissioned  or 
when existing services are reviewed, as well as funding availability.  

At the time of Benjamin’s death, a previous version of the PGM was in effect that did 
not include these items. The PGM available at the time (and still present in the current 
version) includes guidance on ‘behaviours this scheme does not ordinarily cover’. 
Paragraph 7.4.14 of the PGM states:  

“consideration  should  be  given  as  to  the  history  and  circumstances  of  a  patient 
including: 

•  wherever  the  behaviour  can  be  ascribed  to  a  condition  capable  of  being 
rapidly  alleviated  by  treatment,  eg  mental  health  illness  or  medical/acute 
conditions with known behavioural changes (eg head injury) 

•  whether it relates to a patient who has never been aggressive before and/or 

who is clearly suffering mental or physical distress 

•  careful  consideration of  any  mitigating  circumstances  must be given  as  to 
whether a referral to the scheme is in the best interests of the patient.” 

SAS  services  exist  to  provide  a  secure  environment  to  patients  who  have  been 
removed  from  their  GP  practice  and  allocated  to  the  SAS  scheme,  so  they  can 
continue  to  receive  primary  medical  services  (GP  services).  SAS  providers  are 
commissioned  to  deliver  primary  medical  services  (through  GP  practices)  with 
additional  safeguards  in  place  for  supporting  violent  patients.  This  will  include,  for 
instance,  ensuring  that  staff  have  a  sufficient  training  and  skill  mix  for  supporting 
violent  patients,  security  provisions  and  considering  patient  rehabilitation  needs  for 
addressing  any  contributing  factors  which  may  be  influencing  the  behaviour.  Aside 
from ensuring patients have continuing access to GP services, the aim of the SAS is 
to support rehabilitation and discharge patients back into mainstream GP services.  

When  patients are  in  the  SAS,  they  can  expect  to  receive  the  full range of  primary 
medical  services  as  would  be  provided  at  any  other  GP  practice  and,  as  such,  the 
provision  to  receive  appropriate  clinical  care  and  treatment  is  already  a  given 
expectation of service.  

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 
Benjamin, 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