Coroner warns of autism assessment delays after death of nine-year-old boy

A coroner has written to two ministers after concluding that a nine-year-old schoolboy who died after waiting three years for an autism assessment may have lived had he been diagnosed earlier.

Josepth Bitsakaki, known to his family as Joe, died last September at his home. His inquest determined that his death was due to misadventure, as the available evidence suggested he had not intended to end his life.

At the time of his death, he was in the early stages of an assessment process to confirm if he had autism, despite having been waiting around three years for an assessment to take place. His family told the inquest that had he been assessed and diagnosed earlier, they may have been more able to deal with him when his behaviour was at its most challenging.

Following the inquest, Alan Wilson, Senior Coroner for Blackpool and Fylde, sent a Prevention of Future Deaths (PFD) report to junior ministers at the Department for Health and Social Care and the Department for Education, as well as Children’s Commissioner Rachel de Souza.

The PFD report stated: ‘The court was informed that he had waited around three years for assessment. This was immensely frustrating. His Parents regularly learned that young people perceived to be more challenging were added to the waiting list at a much later stage, and allocated a place higher up that waiting list, with the inevitable consequence that Joe’s assessment was further delayed.

‘In April 2022, there was finally some progress and they became aware that the assessment process was to commence, but as it turned out not in sufficient time for him to have been assessed, diagnosed, and for his parents to be given the help they feel they needed to support him before he died.’

The report added that Bitsakaki’s parents believed that once assessed, he would most likely have been diagnosed with Attention Deficit Hyperactivity Disorder.

Wilson raised the assessment delays as a matter of concern in the PFD report, stating that ‘there is a risk that future deaths could occur unless action is taken’.

‘With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required, but there must surely come a point whereby, notwithstanding those finite resources, the wait for assessment is taking too long,’ the PFD report said.

‘The wait for assessment placed Joe at risk, and other children will be similarly at risk in the absence of a timely assessment.

‘It is possible that had he been diagnosed earlier, and with enough time for the relevant professionals to have been able to carry out some meaningful work with him, and had his extremely supportive Parents been given more support, Joe’s death may have been avoided.’

The recipients of the PFD report are under a duty to respond by 23rd May.

Image: Annie Spratt