Clare Evans of MW’s specialist inquest team represents the bereaved family of Robin Richards. The lengthy inquest into Robin’s death concluded on 9th March 2015.


Clare Evans
Clare Evans
Solicitor - Civil Litigation

Robin’s death highlights the lack of provision in the community for those diagnosed with Asperger’s Syndrome. The ongoing concern gave rise to the Coroner’s decision on 9th March 2015 to prepare a ‘Report to Prevent Future Deaths’, which will be sent to the Department of Health to respond to.

The Coroner will also send a report to Somerset Partnership NHS Foundation Trust arising out of the concerns highlighted at this inquest.

The jury at Somerset Coroner’s Court found that the following factors contributed to Robin’s death:

  • Communication
  • Training
  • Information-sharing
  • Discharge planning
  • Care planning
  • Risk assessment

Robin died on 3rd July 2015, aged 33, further to hanging himself from a staircase at Highbridge Court in Somerset, on 29th June 2015. Highbridge Court is a private Care Home run by Tracscare (now re-branded ‘Accomplish’), which at the time, advertised itself as a specialised forensic Mental Health service.

Robin was transferred to Highbridge Court on 15th June 2015, followed a prolonged in-patient stay - initially detained under the Mental Health Act before becoming a voluntary in-patient - on a psychiatric ward at Wellsprings Hospital, Taunton.

It is well-documented that the transition from in-patient care to the community is a time of high-risk of suicidality, particularly in the first two weeks after hospital discharge.

In spite of this, when Robin was transferred to Highbridge Court, independent expert evidence confirmed the view Robin’s discharge was not adequately planned for, and staff at Highbridge Court had not been informed by staff of Somerset Partnership NHS Foundation Trust, of the potential risk of harm from Robin, to himself.

The incident on 29th June followed a 2 week period in which Robin regularly expressed suicidal thoughts, and had started to act upon his thoughts by harming himself, including walking in front of moving traffic.

The inquest heard evidence of

  • failings in risk assessment and management;
  • Robin’s family being left out of key discussions and meetings around his care, discharge and risk management;
  • Highbridge Court failing to communicate the full breadth of Robin’s self-harming behaviours to the family or the Trust’s Community Mental Health and Crisis teams;
  • lack of training of care home staff regarding Asperger’s and what to do if someone was found hanging

Details of the Preventing Future Deaths Reports to the Department of Health and Somerset Partnership NHS Foundation Trust are eagerly awaited. The family hope that lessons will be learned from Robin’s tragic death, so that others with similar presentations will not have to suffer the same fate.

This inquest is timely given the recent Guardian article which reveals fundamental shortcomings in mental health care provision, which puts lives at risk. For example, failures in training, flawed processes and errors in judgement (link to article below).

Further, it is understood there are ongoing concerns in relation to other Tracscare Homes in England and Wales, linking into the broader national concern as to the increasing use of private care homes for the purpose of mental health care provision. It is of note that under the Human Rights Act, private care homes can be ‘public authorities’ and, therefore, obliged to comply with the European Convention on Human Rights.

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