Myles Scriven

. Calderdale and Huddersfield NHS Foundation Trust

. NHS England (Reg 28 Reports)

I am Crispin OLIVER, HM Assistant Coroner for the coroner area of West Yorkshire Western Coroner Area

On 03 May 2023 I commenced an investigation into the death of Myles Edward SCRIVEN aged 31. The investigation concluded at the end of the inquest on 11 July 2025. The conclusion of the inquest was that: Myles Edward Scriven died a natural death to which neglect contributed.

Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. Contributing to the cause of his death was lack of adjustments for his Autism and Learning Disabilities resulting in incorrect decision making as to his care and medication.

During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken.  In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The rider of Neglect attaches to the actions of the Calderdale and Huddersfield NHS Foundation Trust (‘the Trust’). It relates to the lack of adjustments, that were identified as being required to treat Myles safely in the context of his Learning Disabilities (‘LD’) and Autism notably during his admission 20-25 October 2022. It is true that evidence from Trust witnesses has been sufficient to demonstrate that the Trust is aware of the issues arising in this case at least in terms of training and professional input. It has an ongoing programme of training in relation to Learning Disabilities and Autism in clinical care and they have people in post enhancing Learning Disability provision. The crux of the remaining concern is in relation to auditing the impact of all of this in terms of auditing the outcome of this work. To be fair, Trust evidence was that there is now auditing of mental capacity assessments and there is dedicated nursing leadership walkaround of all wards auditing LD and autism policies being applied. However, there is this remaining evidential reality: much of what is now in place was already in place in 2022 – not least key personnel who gave evidence at the Inquest, but also VIP passports, training and all the underlying regulatory underpinning. But in Myles’s case it simply had no impact whatsoever. One witness’s own ‘spot-on’ entries in the EPR on 21 October were just were not acted upon by colleagues and had zero effect when she went on leave thereafter. Clinicians were applying Mental Capacity Act principle 1 but not 2. ‘Culturally’ speaking, that one obtaining in secondary care after the witness went on leave seems to have been stuck in another era. So, the question is – how it is proposed to ensure full compliance with best practice and by when?

In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action.