Matty Sheldrick

Following their discharge, Matty’s mental health continued to deteriorate. The reasonable adjustments they requested could not be accommodated by the crisis team and they were discharged from the service before the date of their initial assessment with community secondary mental health services (ATS).  

On 2 November, Matty called the Mental Health Rapid Response service after ligaturing and while feeling suicidal. Matty was taken to A&E for assessment.   

Over the next two days, Matty attempted to ligature in the hospital multiple times.  

Following an assessment under the Mental Health Act on 4 November, Matty was told they could leave hospital if they wished. The inquest heard evidence from a junior doctor who recalled Matty begging and pleading with professionals, telling them they could not keep themselves safe and would die if they left hospital. She told the inquest it was the worst day of her career and one she will never forget.  

Matty left the A&E department shortly after 9pm. At around 10.45pm, Matty ligatured outside the hospital. They were admitted to the intensive care unit just after 11pm and died 17 days later. 

The Coroner found that Matty died after ligaturing, and that their intentions at the time of carrying out this act remain unclear. The Coroner found that the following issues contributed to their death: 

1. The fact that Matty’s private housing accommodation was not suitable due to their ongoing sensory issues.
2. There had been no psychiatric bed available to Matty during their first admission to A&E in September. They stayed in A&E for 26 days. This meant there was no meaningful therapeutic input at that time.  
3. The fact that A&E was not a suitable environment for a neurodivergent individual and the 26 day period of their stay contributed to their mental health difficulties.
4. There was a general lack of inpatient bed provision for informal patients and in particular for those who are autistic and non-binary who require to be on a mixed ward.
5. Matty was discharged from the Crisis Resolution Home Treatment Team on 18 October 2022 before being picked up by the Assessment and Treatment Service. This left a gap in provision for Matty.
6. The rigidity of the referral process to Transforming Care in Autism Team meant that Matty was unable to access specialist advice and resources whilst in A&E or in the community.
7. The mental health assessment carried out during the second admission did not take into account the following:
   1. The views and observations of the nearest relative, Matty’s mother.
   2. Matty’s preferred communication aids and in particular Matty’s communication book.
   3. The need for Matty to have an advocate present during the assessment and give consideration to the use of idiosyncratic language.
   4. The extent of Matty’s deteriorating mental state and their increasing risks in the context of their neurodivergence.
   5. Too much emphasis was placed on Matty's presentation within the assessment itself.
   6. The fact that Matty’s change of behaviour during the assessment may be due to:
      1. The fact that Matty had been given diazepam
      2. The fact that Matty may have been able to mask their distress 

8. There was a lack of discharge planning documented after the assessment on 4 November 2022 particularly if Matty decided to leave before the morning. This led to confusion within the A&E department when Matty decided to leave the hospital. 

The Coroner will also be making two Preventing Future Deaths reports arising from her concerns around the lack of availability of inpatient mental health beds.  

Shelagh Sheldrick, Matty’s mother, said:  

We are beyond heartbroken that Matty is no longer physically with us and that his journey in life was so hard due to the difficulties in accessing appropriate support. He suffered so much when reaching out to those who were supposed to support and protect him; this knowledge has caused the family such deep pain. Both trusts failed to involve the family in his care. As Matty’s crisis deepened and he started to self-harm repeatedly in hospital I was not informed of his distress; I was not informed Matty would be receiving a Mental Health Act assessment, nor was I informed that Matty had left the ward less than an hour after the assessment with no immediate crisis or safety plan. Matty didn’t want to die, he asked to be kept safe but was rejected from the very place people in crisis are told to go.   

We appreciate that the Coroner recognised the extensive failings that contributed to Matty’s death. We can only hope that this tragedy and Matty’s voice being heard will protect others in the future. 

Our family would like to take this opportunity to thank the support provided by INQUEST and the work they continue to do and for our dedicated legal team who believe as strongly as we do that what happened to Matty was so very wrong. 

Gray Hutchins, CEO of The Clare Project, said:  

The Clare Project welcomes the Coroner's conclusions and are grateful to have been provided the opportunity to contribute to the inquest of our much loved member Matty Sheldrick. Like many people failed by our growing gaps in health and social care, Matty was not a single-issue person. Adequate mental health support for neurodivergent people, particularly those who are Autistic, and often trauma experienced, is inherently non-existent. Provision for Matty was further dwindled by being a member of our trans and non-binary community.  

We look forward to the release of the Coroner's Prevention of Future Deaths Report, and subsequent responses from those within both national and local health systems who continue to fail our loved ones. 

Selen Cavcav, Senior Caseworker at INQUEST, said:  

SPFT has been the subject of long-standing and robust criticism over the past decade from a range of independent bodies including the Coroner's Courts.   

The lack of beds, a one-size-fits-all approach, and the lack of professional curiosity, compassion and care means people continue to die preventable deaths. Unless there is a decisive step to acknowledge the need for urgent action, deaths will be repeated without end. Matty deserved better. 

ENDS

NOTES TO EDITORS 

For further information, interview requests and to note your interest, please contact Jessica Pandian on [email protected]

The family are represented by INQUEST Lawyers Group members William Kenyon of ITN Solicitors and Isabel Bertschinger of One Pump Court. They are supported by INQUEST senior caseworker, Selen Cavcav. ​     ​ 

The family are also supported by The Clare Project, a community-led charity providing support for trans, non-binary and intersex adults. Matty received support from The Clare Project during their time in Brighton. They commissioned artwork for the organisation and was a much-loved service user. They are being represented by Liam Evans (and previously by Sophie Walker) of One Pump Court, with support from Good Law Project.

​​Other Interested persons represented are: Sussex Partnership NHS Foundation Trust, Brighton & Hove City Council Adult Social Care, GP Practice WellBN, University Hospital Trust, The Clare Project, Sussex Integrated Care Board, and Dr Robert Sparkes.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests. 

Deaths in the care of Sussex mental health services: 

• Morgan-Rose Betchley, 19, died a self-inflicted death whilst a voluntary mental health inpatient at Meadowfield Hospital on 9 March 2023. Morgan was autistic and had a history of mental ill health including self-harm when distressed. An inquest found multiple failings in her care contributed to her death. Media release.
• Ellame Ford-Dunn, was 16 years old when she died after absconding and ligaturing whilst a mental health inpatient at Worthing Hospital. An inquest into her death was adjourned earlier this year.  Media release.
• Jason Pulman, a 15 year old transgender teenager died a self-inflicted death on 19 April 2022 in East Sussex. An inquest found that systemic failures by all of the organisations involved in his care, with the exception of his school, possibly contributed to his death.  Media release.
• Jessie Eastland Seares, 19, died whilst an inpatient at Mill View Hospital in May 2022. Jessie was autistic and had a complex history of neurodevelopmental, physical and mental health issues. A jury found that systemic failures in health and social care led to her death.  Media release.
• Rachel Garrett, 22, died after falling from a height in Brighton on 29 July 2020. An inquest found that opportunities to save her life had been missed. Rachel had mental and physical health needs and had spent time in the care of Mill View Hospital.  Media release.
• The Telegraph reported in January 2022 that more than 360 patients took their own lives after being treated by Sussex Partnership Foundation NHS Trust in the past five years. While there were also 15 coroner’s reports to prevent future deaths.
• Bethany Tenquist, 26, died after ligaturing in her room at Mill View Hospital on 16 January 2019. An inquest found a sequence of serious failures relating to staffing, leadership and safeguarding processes on ward probably had a direct causal connection to her death.  Media release.
• Morghana Woodburn, 18, died a self-inflicted death at Meadowfield Hospital in January 2018. Morghana was diagnosed with PTSD and EUPD. She was moved seven times between four different hospitals over the nine months leading up to her death. An inquest concluded that she died as a result of her mental health issues which led her to self-harm. Media coverage.
• Janet Müller, 21, was killed after absconding from Mill View Hospital. The jury at the inquest found there were a number of failings in her care.  Media release.
• In 2016, local media reported that five women had died at Mill View Hospital, including Janet Müller (above), Danuta Corbett, Jessica Philpott, Jackie Stansby, and Philippa Mortiz-Parsons.
• Sabrina ‘Sabby’ Walsh, 32, died on the Woodlands Ward in Sussex 2016. The inquest found gross failures and neglect contributed to her death. Media release.  
• Bethan Smith, 31, died whilst under the care of Sussex Partnership Trust in 2011. Her mother  wrote this about their experiences.