BY TOBY PORTER
The parents of a girl who died while she should have been cared for in a mental illness care centre are considering suing the people in charge.
Andrew McCulloch and his wife Amanda from New Cross lost their daughter Colette, 35, in July 2016 soon after she walked out of the centre in Bedfordshire.
She had run away from Milton House Therapeutic Campus (MHTC) at least twice and on the last occasion was walking along the A1 where it had no pavement when she was knocked over and killed by a lorry.
A first inquest had just focused on the accident – but a coroner at a second inquest last week found a string of phases by health management which was caring for her and running the home she had been placed in.
The health authority East London and Soho NHS Foundation Trust (ELFT) have now asked Colette’s parents to advise on how to look after autistic adults.
Pathway House, the home she was staying in run by MHTC has said it is reviewing its procedures. But Mr McCulloch, an actor who has starred in Coronation Street, The Chief and The Bill, is determined to make sure the changes are effective.
The second, unprecedented inquest was only called after the McCullochs, backed by solicitors Leigh Day, lodged a judicial review to force Colette’s care to be taken into account.
The first coroner, Ian Pears, recused himself and the second one, Martin Oldham, said at the conclusion of the second, last week, that Colette’s death was “an avoidable tragedy”.
He said: “In 2014, an assessment of Colette found that she did not have the capacity to keep herself safe and she was very vulnerable.
“She was failed by the lack of mental health assessment and by an inadequate regime at Milton Park which left her at large on the day of her death for far too long.
No one will ever know how she came to be on the A1, but it is there she died.
“The move to Pathway House was a disaster. The records show a disastrous situation and it is difficult to understand how Colette was being helped at all.
“The investigation was never about a road traffic accident. “She was failed by the lack of a mental health assessment and by an inadequate regime.”
Andrew said: “We were very pleased with the conclusions of the inquest. The new corner was excellent. He conducted the inquest superbly.
“He didn’t rush anything, was thoughtful and considerate, asked intelligent questions and had read all the paperwork.
“We are still this very disappointed with the Ministry of Justice though and the coroner’s ombudsman who rejected our complaints about the initial inquest until we threatened a judicial review.
“The next step is to ensure it won’t happen to anyone else – that the action plans are actually carried out, particularly by Milton Park.
“We intend to press to make sure that happens. Our lawyers are working on it.”
ELFT sent a representative to the inquest every day, admitted its failings and have asked the couple to help them remodel their procedures on how care for high-functioning autistic women and girls.
Andrew said: “We are going to work with them on how they will restructure their services. Their structure wasn’t fit for purpose.
“It was dysfunctional. They do want to change. We have heard that before – but the people we met seemed to be genuine so we are setting up meetings and see that as a positive outcome – even if there is a long way to go.
“We want to see evidence Milton House have reviewed procedures and taken action to put things right. “They were defensive and unhelpful throughout the whole process.”
The couple plan to use the findings of a Care Quality Commission report and a safeguarding adults review report by Pete Morgan to force action.
Andrew said: “Milton House have no real understanding about autism. They claim to be taking online courses from University of Coventry on how to care for autistic adults. But the only one I can find is one for £30 which is a primary school-level understanding of autism – unless there’s of course I missed. That is very telling.
“Milton House had a PR man at the inquest every day for the seven days and they made no comment about the treatment – their statement was all about presentation.
“They are 90 per cent funded by the NHS but they are a private clinic so they are employing a press relations consultant at a cost to the NHS. “I think that’s unacceptable and highly dubious.
“We may have to take out a civil case for costs and use that to try to get them to admit their failures.
“We expect them to put those failures right. They have glossy brochures which promise all sorts of things but they are not up to it and they just couldn’t deal with Colette’s problems.
“We want to make sure the system is not loaded against families who have been bullied while when they try to make a complaint.
“It was the scariest thing we have ever had to do.” The couple had faced a potential legal bill for the judicial review of £50,000 and will now try to claim some of that back through the courts.
Andrew said: “It was only because we had very reassuring and understanding lawyers and we’re able to get some money through a crowd justice appeal that we could begin the process of starting a judicial review.
“The Ministry of Justice and the ombudsman blocked everything we tried to do. “The backing we got from the crowd justice appeals made a massive difference.
We have a lot to thank our funders for.” A spokeswoman for Pathway House said: “Following Colette’s death in July 2016, we conducted an in-depth internal investigation and by working closely with our local authority and health service partners we have changed our joint working processes to prevent an event like this happening again.”
A spokesman for ELFT said: “Following Colette’s death in 2016, internal and independent investigations were held to understand how and where the NHS and other agencies failed to provide Colette with the care and support she needed.
“We have listened, learned and made changes to improve how we provide services as a result of this tragic incident.”
A spokeswoman for Central Bedfordshire council said: “The inquest process has illustrated with painful accuracy how terrible the untimely death of Colette McCulloch was.
“While nothing will console her parents, we feel it’s important that they know how sorry we are for their loss.
“Many agencies were involved with Colette and it is now clear that there were failings throughout the system which meant that she did not receive all the support that she needed and which should have been provided.
“In circumstances like this, it is vital that the professional practice of the various agencies that were involved should be thoroughly reviewed, which is why there was an independent Safeguarding Adults Review.
“While Colette was accessing mental health services in the Bedford area, Central Bedfordshire council was involved in the commissioning of these services with Bedford Borough council.
“Working together with the borough and ELFT who provided services on our behalf, we have worked closely to review the service, learn from Colette’s experience and implement changes to how the service is provided and monitored.”
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