GROSS failures in the care given to a bullied autistic teenager who died when he threw himself in front of a train at Marsden amounted to negligence, a coroner ruled.
Gareth Oates, from Stowmarket, Suffolk, 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 he 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.
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, 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.”
The inquest heard that Gareth was diagnosed with high functioning Autistic Spectrum Disorder when he was five and had specialist help throughout his pre-16 schooling, often on a one-to-one basis
Earlier this week, Mrs Oates told the inquest how Gareth had been bullied at secondary school but this was dealt with.
She added: “Until I started to kick up a fuss, nobody did anything.”
Gareth eventually started a course of cognitive behavioural therapy in September 2009.
His mother described how he became obsessed with the 1985 action film The Runaway Train – which ends with one of the main characters killing himself in front of the locomotive.
Mrs Oates said she believed some of the details of her son’s death mirrored that in the film.
She told the coroner she believed her son travelled to the Huddersfield area because he had once been obsessed with a DVD about the last days of steam engines in the Pennines, which featured the spot where he died.
After the hearing, Mrs Oates thanked the coroner and said she hoped his recommendations would be acted on by all the agencies concerned.
She said: “I hope that the lack of appropriate services for young people with autism such as Gareth will soon be a thing of the past.
“I continue to be deeply saddened by Gareth’s death, as do the rest of his family.
“We hope that other young people with autism will be better protected in the future.”
