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Consultant’s “prejudice” led to failings in care of autistic child
31 May 2023

A young man who suffered catastrophic injuries in a suicide bid was failed by the mental health team which should have cared for him.

Jesse Western, 17 living in Norfolk, suffered a fractured skull and a brain haemorrhage when he stepped in front of a lorry just three days after being discharged from the Queen Elizabeth Hospital Kings Lynn in June 2020.

Jesse, supported by his mother Stella Owens, is now awaiting compensation after the Norfolk and Suffolk NHS Foundation Trust admitted numerous failings in Jesse’s care that eventually led to his attempt on his own life.

Michael Portman-Hann, an associate in the clinical negligence team at legal specialists FBC Manby Bowdler, said the problem stemmed from the attitude of the consultant psychiatrist, Dr Lauren Coates, towards Jesse’s mother.

He said: “The doctor in the children and young people’s mental health team decided at Jesse’s first appointment in 2015 that, although he had autistic traits, the behaviours Jesse was showing were because of his mother’s parenting. As a result, she refused to give Jesse the diagnosis of autistic spectrum disorder which would have meant a treatment plan was put in place for him.

“To compound the damage, the consultant also refused to accept the diagnosis of a later private assessment that found Jesse did indeed have ASD.

“When Jesse ended up in hospital five years later, the same consultant refused to do a full assessment of his health. After Jesse was detained under the Mental Health Act by other hospital staff, because of a serious deterioration in his condition, the consultant revoked the order without assessing him in person.

“This was a catalogue of decisions made on the basis of personal prejudice against Jesse’s mother and not on the clinical needs of Jesse himself. The trust agrees that had Jesse had a proper treatment plan, including the option of medication, he wouldn’t have got himself into the state that drove him to attempt suicide.”

Ms Owens said her son was now living with the consequences of poor care. She said: “When Jesse had his first appointment in 2015, the consultant fixed on me and my parenting, saying Jesse’s behaviour was his way of getting his needs met.

“She couldn’t - or wouldn’t - get past that. Had she made an ASD diagnosis at that point, we would have had a treatment plan and some tools to prevent Jesse’s anxiety reaching crisis point.

“When the community psychiatrist gave Jesse a short course of medication, we noticed a big improvement is his state of mind, but this was never followed up and he wasn’t assessed for regular medication.

“None of this should have happened and Jesse should never have got to the point where he felt he had no other way out.”

“As a result of the Trusts’ failures Jesse has lost out on so many opportunities which could have been awarded to him had he received an earlier diagnosis of Autism Spectrum Disorder. This has had a substantial effect on his education and Jesse feels he has missed out on being able to enjoy his formative years”.

After the trust accepted the failures in Jesse’s care, chief executive Stuart Richardson wrote to Ms Owens and to Jesse to apologise.

He said: “I offer my sincere apologies for the trust’s failures to appropriately manage Jesse’s Autism  Spectrum Disorder and to undertake a comprehensive psychiatric assessment following his admission to the [hospital].

“I was desperately saddened to hear that had a psychiatric assessment occurred prior to his discharge home, this is likely to have avoided Jesse’s attempt to take his own life.

“I am truly sorry that the trust failed you both and for the impact this has had on you and the wider family. The Trust always strives to provide the highest quality of care to its patients, and I can assure you that the failings identified in care on this occasion have been shared with all practitioners and agencies involved with the intention of learning and ensuring no one else should suffer this experience.”

Meet Michael Portman-Hann