AN AUTISTIC teenager suffered “gross failings” in the care he was given before he threw himself in front of a train, a coroner has found.

Speaking after the inquest into her 18-year-old son Gareth’s death in Bradford yesterday, Glenys Oates said she hopes other young people with autism would be better protected in the future.

The inquest found that Gareth, from Stowmarket, had been let down by a number of agencies, including those dealing with mental health, social services and education.

Bradford Coroner Professor Paul Marks said it was probable that treatment with certain drugs or the appropriate use of the powers under the Mental Health Act would have “averted his death”.

Suffolk County Council, the Norfolk and Suffolk NHS Foundation Trust and West Suffolk College - where Gareth was a student - have all responded to the verdict.

The council said it had implemented significant changes as a result of the Autism Act and will study the coroner’s report to see what other lessons can be learned, while the NHS Trust said improvements had already been made and the college said it took all cases of bullying “very seriously”.

The inquest heard that Gareth, a lifelong train enthusiast, had already tried to kill himself and had talked of suicide since the age of 11.

He died instantly on March 2, 2010, when he was hit by a train after travelling to Marsden Station, near Huddersfield, West Yorkshire.

A three-day inquest in Bradford was told that Mrs Oates had mounted a desperate battle to get appropriate mental health intervention for her son in the run up to his death

After the hearing, she thanked the coroner and said she hoped his recommendations would be acted on by all the agencies concerned.

She said: “I hope that the lack of appropriate services for young people with autism such as Gareth will soon be a thing of the past.

“I continue to be deeply saddened by Gareth’s death, as do the rest of his family. We hope that other young people with autism will be better protected in the future.”

Professor Marks said there was a clear gap in provision in psychiatric care for young people between 16 and 18 years old who were too old for child services but too young to benefit from adult interventions.

He said this was probably a national problem and he said he would be writing to the Secretary of State for Health and the Royal College of Psychiatrists about his concerns

In a narrative verdict, Prof Marks said there were gross failures in the assessment and management of Gareth’s case as well as the access he was given to specialist services “amounting to negligence.”

Earlier, the coroner said: “There was a lamentable lack of a named expert in autism to take overall charge of his care and adopt an holistic approach to his needs.”

The coroner said he accepted evidence that cognitive behavioural therapy was not enough in Gareth’s case and “pharmacological treatment should have been tried”.

He said: “Although no one individual’s failing can be identified, the summation of failings in his psychiatric management amounted to gross failure in the care delivered to him.”

Norfolk and Suffolk NHS Foundation Trust that “failed” Gareth says it has already made improvements to services.

Chief executive Aidan Thomas said the trust was piloting a scheme to “bridge the gap” between child and adult services and reach out to marginalised groups of young people with complex mental health needs.

“On behalf of the former Suffolk Mental Health Partnership Trust I would like to express our condolences to the family of Gareth Oates at this distressing time,” he said. “Now the verdict has been given and recommendations have been made we note that the coroner identifies a failure in the system.”

He added: “I appreciate these improvements are being made too late for Gareth but we are determined to learn from what happened and with our partners will make real changes.”

Martyn Wagner, vice-principal of business and community at West Suffolk College, said staff took all reports of bullying very seriously.

“The college carried out a thorough investigation at the time of Gareth’s tragic death in 2010,” he said.

“College staff had no knowledge of Gareth being called names by other students or evidence of bullying while attending college.”

He said Gareth, pictured below, was supported by teaching staff and the student welfare team during his time at West Suffolk and appeared to be coping well with his course.

He added: “We are very sorry for Mrs Oates’ loss. Everyone at the college who knew Gareth was very upset, and we offered support to staff and fellow students at the time.”

Graham Newman, Suffolk County Council’s portfolio-holder for children, schools and young people’s services, said Gareth’s death brought to light issues in the way mental health and social care services were delivered to people with high-functioning autism but the issues were not specific to Suffolk.

“A serious case review, completed in March 2011, led to major improvements, including more specialist knowledge of autism, staff training and changes in the way people move between support services,” he said.

“I feel sure all the agencies involved were, like Suffolk County Council, devastated when Gareth took his own life and would wish to again express deepest sympathy to his family.

“We have already implemented significant changes as a result of the Autism Act and will now study the coroner’s report in great detail to see what other lessons can be learned by us and all agencies that support people with autism.”