GROSS failures in the care given to a bullied autistic teenager who died when he threw himself in front of a train amounted to negligence, a coroner said today.
Gareth Oates died instantly a month after his 18th birthday when he was hit by a train after travelling to Marsden Station.
A three-day inquest in Bradford heard how Gareth, from Stowmarket, Suffolk, was bullied while he studied at West Suffolk College, in Bury St Edmunds, with some students routinely calling him "suicide boy".
Bradford Coroner Paul Marks heard how Gareth's mother, Glenys Oates, mounted a desperate battle to get appropriate mental health intervention for her son in the run up to his death on March 2, 2010.
He had already tried to kill himself once and had talked of suicide from the age of 11.
Today, Professor Marks said Gareth was failed by a number of agencies including those dealing with mental health, social services and education.
He said it was probable that treatment with certain drugs or the appropriate use of the powers under the Mental Health Act would have "averted his death."
The coroner said there was a clear gap in provision in psychiatric care for young people between 16 and 18 years old who were too old for child services but too young to benefit from adult interventions.
He said this was probably a national problem and he said he would be writing to the Secretary of State for Health and the Royal College of Psychiatrists about his concerns.
In a narrative verdict this morning, Prof Marks said there were gross failures in the assessment and management of Gareth's case as well as the access he was given to specialist services "amounting to negligence."
Earlier, the coroner said: "There was a lamentable lack of a named expert in autism to take overall charge of his care and adopt an holistic approach to his needs."