Gross failures and significant missed opportunities by Surrey authorities involved in the care of Oskar Nash

The Coroner concluded that there were gross failures which amounted to neglect and missed opportunities by the organisations and authorities involved in Oskar’s education, care and support, which more than minimally contributed to his death.

Senior Coroner Richard Travers said in his conclusion there was neglect in relation to a referral made to children and adolescent mental health services (CAMHS) by Oskar’s GP in September 2019. The Coroner said there were gross failures in CAMHS management of the referral as they failed to undertake a clinical assessment of Oskar’s needs.

The Coroner said that if CAMHS, which is run by Surrey and Borders Partnership NHS Foundation Trust, had carried out a proper review of the information then he was satisfied that a clinical assessment of Oskar would have taken place, and that his death probably would have been prevented.

Oskar Nash

The Coroner found that there was also a series of failures by Surrey County Council (SCC) including a failure to place Oskar in an appropriate school and a failure to ensure his education health and care plan (EHCP) contained sufficient information regarding his health needs and previous suicidal thoughts, as well as a failure to provide effective interventions or support.

Mr Travers said that it was “astonishing” that a child with Oskar’s complex needs could move from special school to a mainstream school without the schools sharing records. He added that it was “surprising and concerning” that Cobham Free School did not seek to see the records and that information sharing to safeguard Oskar did not take place.

In his conclusion the Coroner said there were clear and serious failures by CAMHS in May 2016 and earlier to ensure Oskar was clinically assessed. He added that these missed opportunities are of particular significance because intervention at an early stage can be particularly effective. The Coroner found that there were further serious failings by CAHMS when Oskar’s behaviour deteriorated at the end of 2019, demonstrating an obvious sign of increased risk.

The Coroner also criticised SCC’s response to this crisis period from the end of 2019, which he said reflected a marked failure to act on the serious risks Oskar faced. The service provided no effective support at all to Oskar or his mother.

The Article 2 inquest was heard over 21 days at Surrey Coroner’s Court. The Coroner will hold a further five-day hearing beginning on 29 November 2021 to discuss Prevention of Future Deaths reports relating to the failures in Oskar’s care.

Oskar died on 9 January 2020 close to a level crossing in Egham, Surrey. He had Asperger’s Syndrome and the inquest heard that his mother, Natalia Nash, had experienced a long and difficult struggle to obtain support for Oskar from social services and the community mental health team.

Natalia told the inquest how she had desperately tried to get help for Oskar, including contacting social services for help in 2018, telling them she could no longer cope with caring for him. They finally visited Oskar following a serious incident at his school for children with special educational needs, but after only one hour concluded that Natalia “kept a nice home” and decided to close the case.

Oskar moved from St Dominic’s School to Cobham Free School, a mainstream school, in February 2019 and initially everything went well, but his behaviour began to deteriorate in November 2019 and he stopped attending school and began staying out late at night. It emerged during the inquest that Oskar’s transfer to Cobham Free School was based on an education health and care plan (EHCP) which was almost three years old.

Following repeated calls from Natalia, social services finally appointed Oskar a youth worker, who made one home visit but did little more because Oskar did not want to speak to her.

The inquest heard that six weeks before he died, Oskar was at ‘red level’ on his school’s risk register because of incidents of self-harm and absences from school. He had gone missing a number of times and so social services had a duty under Section 47 of the Children Act 1989 to make enquiries to decide whether to take any action to safeguard Oskar to protect him from serious harm. A meeting was set up for this purpose in November 2019 but no one was present from the education department at Surrey County Council and Natalia knew nothing about it.

A further Section 47 meeting was set up but was abandoned because the social services representative could not be found. It was then rescheduled at short notice so the school’s representative, the deputy head of inclusion, sent a member of the pastoral team in her place. The person chairing the meeting from social services had no knowledge of Oskar’s case and important information about Oskar available to social services was not considered in advance. The mental health team was not invited. At this meeting it was decided Oskar did not meet the threshold for further assessment and support.

By 2016 there had been six referrals of Oskar to CAMHS but no clinical assessment took place. The last of these referrals made by his GP in September 2019 was marked urgent. However the mental health team dealt with it as a routine referral and referred him to counselling with an external organisation, Relate. Oskar had not been seen by CAMHS or by Relate when he died four months later.

Following the conclusion of the inquest Natalia Nash said:

“Oskar was a boy with a huge smile which could light up thousands of candles. He was a very caring boy who loved exploring nature and making things.

“Life was not always easy for Oskar but he showed great courage in overcoming difficulties and managed to achieve even when things were a struggle. I always felt that Oskar wasn't understood by the professionals around him, and as a result he didn't get the support he needed.

“It is crucial that all of the authorities that have a part to play in supporting autistic children have proper procedures in place to communicate with each other and work together in the best interests of the child, instead of trying to pass on the responsibility to someone else, like they did with Oskar. Professionals must be properly trained in dealing with autistic children and those with Asperger’s syndrome. I would hate for anything like this to happen to another family and I hope that those involved with Oskar will make significant and urgent changes to their procedures going forward.”

Anna Moore, solicitor at Leigh Day, added:

“It was clear from the inquest that all agencies and organisations involved in contact with Oskar failed to recognise that his increasingly challenging behaviour stemmed from his disability and was a cry for help. When Oskar refused to engage with adults or service providers, there is evidence that they withdrew and offered no further support to him or his mother. Inadequate adjustments, or none at all, were made to accommodate his disability and by failing to make adjustments for his condition, Oskar’s voice was not heard.

“Oskar’s family are grateful for the detailed investigation carried out by the Coroner and will continue to participate in the process with the Coroner when he considers whether any further action is required to keep other children safe.”

Jodie Anderson, Senior Caseworker at INQUEST, said:

"Oskar was a vulnerable child with complex needs who was plainly let down by the agencies who should have been there to support him and his family. His death is marred by a litany of shocking failures and missed opportunities. The evidence heard at the inquest showed that social services failed to share information internally and had not provided even basic autism awareness training for staff who were responsible for engaging and supporting Oskar. The effect of this was that Oskar's communication needs were completely overlooked. Training should be mandatory for all state agencies engaging with autistic children. This one size fits all approach has continued for far too long and has already cost so many lives."

Natalia was represented by Anna Moore and Dan Webster of Leigh Day and Angela Patrick of Doughty Street.