NHS care contributed to autistic man's death - coroner

A coroner has said there was a lost opportunity in the care of a 32-year-old man at a hospital that "materially contributed" to his death.

Tom Parsons, from East Grinstead in West Sussex, died in July 2024 from complications caused by blood clots, having been admitted to East Surrey Hospital a few weeks earlier suffering psychosis.

An inquest at Surrey Coroner's Court heard that for 14 days he was not given his prescribed blood-thinning injections because of safety fears about administering them.

Dr Ed Cetti, chief medical officer at Surrey and Sussex Healthcare NHS Trust, offered his "sincere condolences" to Parsons' loved ones and said it was a "difficult and distressing case".

"We are committed to fully cooperating with the coroner," he added.

Coroner Dr Karen Henderson said on Tuesday that while there were multiple factors that contributed to his condition, including Covid and his BMI (Body Mass Index), the failure to administer the drugs was a factor in his death.

She said Parsons - whose family said had autism, epilepsy and learning disabilities - was unable to eat, drink or take medication as he was suffering from psychosis.

He could not comply and sometimes needed five people, including security, to retain him to get medication administered, Henderson added.

The coroner said this was "extremely out of character for Tom who was normally compliant in taking medication".

Speaking after the inquest, Tom's mother, Kim Parsons, said the family felt their voices were "not heard" by some medical staff at the hospital in Redhill.

"Our concerns were not acted upon," she said.

Henderson said there should have been a best-interest meeting with Parson's family and carers to agree on a plan for best supporting him.

There was a failure to involve Parson's family and carers in his care, she added.

Surrey and Sussex Healthcare NHS Trust said in a statement it would carefully consider the coroner's findings.

A spokesperson added the trust would "ensure it learnt from this case to improve the care our patients and their families receive".

Dr Ben Mearns, a consultant in acute medicine and a geriatrician, told the inquest Parsons died because he did not have something he needed for two weeks.

He said his family had not been treated in the way they deserved and apologised.

Outside the court, his mother, Kim, said: "We are so proud of Tom and of everything he achieved in his lifetime.

"From spending time with his beloved brothers to his many volunteering roles, including at the Bluebell steam railway, Tom was passionate in everything he did.

"We remain devastated by what happened and are still struggling to come to terms with this."

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