Jury find systemic failings in health and social care led to death of 19-year-old Jessica Eastland Seares, exposing ‘total inadequate level of community provision’ for those with Autism

4 Dec 2023

A two-week inquest in the Brighton and Hove Coroner’s Court before HMSC Penelope Schofield has concluded, where evidence was heard relating to the care and support Jessica Eastland Seares (‘Jessie’) received both in the community, and latterly on the Caburn Ward at Mill View Hospital when detained under the Mental Health Act before her death.

Jessie was diagnosed with Autism Spectrum Condition, Post-Traumatic Distress Disorder, Attention Deficit Hyperactivity Disorder, Ehlers-Danlos Syndrome. At the time of her death, she was also under neurological investigations relating to seizures that she was experiencing.

A jury has returned a conclusion that “systemic failures in health and social care led to a series of events which caused the deceased periods of dysregulation culminating in regular bouts of self-harm which ultimately ended in death by misadventure”.

HMSC Penelope Schofield has decided to issue a Preventing Future Deaths Report to the Secretary of State for Health and Social Care, stating as follows:

“Sadly, this case yet again exposes the total inadequate level of community provision for the care and treatment of those with suffering with Autism. This is a national problem and sadly leads to many experiencing unnecessary admission to inpatient facilities and also A&E attendances.

Despite a report from the Health and Social Care committee from 2021 there sadly does not seem to have been any real improvement and more lives are likely to be lost. Reading from this report, it says “The conclusion of this report was that Autistic people (and people with learning disabilities) have the right to live independent, free, and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so.”

The report goes on to say that “the community support and provision for autistic people (and those with learning difficulties) and financial investment in those services is significantly below the level required to meet the needs of those individuals and to provide adequate support for them in the community.”

It is very disappointing therefore to hear from the expert witnesses that 2 years on there does not seem to be any improvement in this provision.

We heard here how East Sussex Council tried over 30 providers to help provide support to Jessie but they could not find a placement so they could only patch together supported housing with temporary care agency staff.   I fear there was not much else they could have done in the circumstances but the lack of facilities nationally (as identified by the Jury)  has contributed to Jessie Death and changes need to be made.

I will be writing a Prevention of Future death to the Secretary of State for Health and Social Care, Victoria Atkins” 

Jessie’s inquest was live-blogged by the George Julian Blog.

Coverage of the inquest (including interviews with Jessie’s parents) can be found here: ITVthe BBC

Jessie’s parents were represented by Angelina Nicolaou, instructed by Chris Callender of Sinclairs Law.

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