Bedford: Man died after mental health service neglect, report says

Luke Wilden was discharged from the Crystal Ward psychiatric inpatient facility in Luton three days before his death, a report said

The death of a "vulnerable" teenager with autism and ADHD was "contributed to by neglect on the part of mental health services", a coroner said.

Luke Wilden, 18, was found dead at his home in Bedford on 22 May 2020.

A post-mortem examination found evidence of cocaine and heroin use.

Senior coroner for Bedfordshire, Emma Whitting, said Mr Wilden's mental health declined after being moved from supported accommodation to independent living after he turned 18.

"He became subject to cuckooing and alcohol and drug misuse," Ms Whitting said in a Prevention of Future Deaths report.

Cuckooing is a practice in which a vulnerable person's home is taken over, often as a base for taking or dealing drugs, or for sex work.

"There was a failure to transition him effectively from Child & Adolescent to Adult Mental Health Services and there was no assessment of his needs to enable provision of an appropriate adult social care package, including suitable accommodation," the report said.

Despite several psychiatric admissions and growing concerns about Mr Wilden's ability to keep himself safe while living independently, there was a "continued failure" by mental health services to carry out a needs assessment for him, it said.

'Inappropriate support'

Three days before his death, Mr Wilden was admitted as an inpatient to psychiatric services after being found unconscious in London following an overdose of the drug spice, Ms Whitting said.

But the next day, 20 May 2020, he was discharged back to his Bedford flat and "immediately met up with a known drug user whom had been cuckooing him previously".

On 22 May he was found dead at his home.

Ms Whitting said his accommodation was "unsuitable" and he received "inappropriate support" which left him "at risk of harmful activity".

"Although there was no determination of civil liability, this previously identified failure as well as the failure to detain him during his final in-patient admission amounted to his death being contributed to by neglect on the part of mental health services," the report said.

Mrs Whitting addressed her report to the chief executive of the East London NHS Foundation Trust, which runs services in the area, and NHS England & NHS Improvement.

The teams have until 13 March to respond to the report with details of any action taken or proposed action to prevent future deaths under similar circumstances.

The BBC has approached them for comment.

A spokesman for the East London NHS Foundation Trust said: "Following Mr Wilden's death, the trust carried out a serious incident investigation which identified areas of care we provide that need to improve across the system.

"Following this, we have made changes and are in the process of putting further improvements in place."