Inquest finds multiple failures by mental health services led to Bedford teenager’s death

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Luke Wilden (18) died in his Bedford flat on 22 May 2020 from cardiotoxicity (heart failure). An inquest has found that multiple systemic failures by Bedfordshire’s mental health services contributed to his tragic and untimely death.


Luke was adopted by Dr and Mrs Wilden when he was just 17 months old. He was diagnosed with high functioning Autism and ADHD, and his mental health problems as he grew up, are believed to be due to foetal alcohol syndrome (FASD) because of his birth mother’s problems.

Luke’s adopted family describe him as “a loving, creative, generous lad with a great sense of humour.” An exceptionally talented musician, Luke could play eight musical instruments, including the piano, baritone, drums, guitars, and the violin, and was mostly self-taught.

He had perfect pitch and could hear a song for the first time on the radio and play it in its entirety within half an hour, without the aid of any sheet music. Luke could also play for hours seamlessly weaving from one piece to the next, without pause.

Luke’s complex mental health problems and behavioural issues meant he had been in the care of social services and living in supported accommodation from the age of 15. He thrived when the appropriate support was provided, but unfortunately, after turning 18, there was a serious failure in transitioning him effectively from Child & Adolescent Mental Health Services to Adult Mental Health Services.

There was no assessment of his needs to enable an appropriate adult social care package to be provided and he was not allocated suitable accommodation.  Instead, on 2 January 2020, he was moved to independent living in a one bed flat in Bedford. This lack of adequate support, led to deterioration in his mental health, and he became a victim of ‘cuckooing’, a term used by the police to describe when drug dealers or addicts take over the home of a vulnerable person and exploit them. Tragically in Luke’s case, this led him down the path to alcohol and drug misuse.

From early February 2020, Luke was admitted to the psychiatric ward of Luton and Dunstable Hospital several times. But despite increasing concerns about his ability to stay safe while living independently, mental health services continued to fail him by not carrying out a needs assessment.

Just three days before his death, in the early hours of 19 May 2020, Luke was found unconscious in London’s Trafalgar Square after a spice overdose (synthetic cannabinoids). He was re-admitted by the Crisis Team to in-patient psychiatric services (Crystal Ward). Despite the fact the Ward had the authority to detain him until alternative living arrangements could be made; he was again discharged back to his Bedford flat in the afternoon of 20 May 2020.

Due to his extreme vulnerability, following his discharge, he immediately met up with a drug user known to the police, who had been cuckooing him previously. After being uncontactable from the morning of 21 May 2020, he was found dead in his flat by his mother and the Crisis Team at around 11.20 am on 22 May 2020. The post-mortem examination revealed evidence of cardiotoxicity arising from cocaine and heroin use.

Inquest findings

In her narrative conclusion, HM Senior Coroner Emma Whitting, said:

“The Deceased was a vulnerable adult who had not been transitioned effectively from Child & Adolescent to Adult Mental Health services on reaching the age of 18.  The consequence of this, together with the repeated systemic failure of mental health services to assess his needs, resulted in him living in unsuitable accommodation with inappropriate support from 2 January 2020 which placed him at risk of harmful activity, including drug use. Although there was no determination of civil liability, this previously identified failure as well as the failure to detain him during his final in-patient admission amounted to his death being contributed by neglect on the part of mental health services.”

Luke’s adoptive parents, Dr and Mrs Wilden, said:

“Although Luke was under numerous Mental Health and Social Care Teams in the community, like numerous young adults he fell through the gaps between multiple services.  It was a case of ‘too many cooks spoil the broth.’

“More than a dozen safeguarding alerts were raised over several months last year.  One alert alone should do the job to ensure the safety of a vulnerable person, but lines of responsibility were unclear, and escalations of care did not happen in time. Too many opportunities to save Luke were missed. We sincerely hope that the services for such people will be tightened up in the light of Luke’s inquest findings.

“As a family we would like to give our heartfelt thanks to Autism Bedfordshire and Carers in Bedfordshire who supported us so well navigating the nightmare of the care system.  It is always a continuous uphill struggle for parents of children with special needs and these volunteers provide an invaluable service.  Many have endured similar situations and understand only too well the challenges, frustration and heartache involved.

“We hope and pray that some good will come out of the tragic loss of Luke for other young people and their families. In Luke’s loving sister, Claire’s words from the song ‘Don’t Stop Believin’ by Journey: He took the midnight train goin’ anywhere.”

Mary Smith, a specialist inquest lawyer from Novum Law, who represents Luke’s family, said:

“The coroner’s conclusion chimes with what Luke’s parents have said all along – that more should have been done to protect this extremely vulnerable young man. He should have been given a robust and comprehensive assessment of his needs to ensure he was given the appropriate living arrangements and care and support he so clearly required. Instead, he was badly let down by the mental health service’s systemic failures.

“While nothing can make up for the tragic loss of Luke, we are satisfied that we have helped his grieving parents secure the answers they wanted. We join them in urging for vital lessons to be learned so that other families with vulnerable young adults don’t have to suffer as they have.”

Our inquest team regularly represents families at inquests providing expert advice and support throughout what can be an overwhelming and challenging process. Click here to find out more about our inquest services. Alternatively, please call our specialist inquest team on Freephone 0800 884 0777 or contact us online for a free, no-obligation chat.

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