Myles Scriven was just 31 when he died in April 2023.
An inquest held in Bradford in July found he died from natural causes contributed to by neglect after poor standards of care by GPs and by doctors at the Calderdale and Huddersfield NHS Trust.
Scriven lived at home with his mother Jane, stepfather Ashley and younger brother James. He was a devoted and much-loved son who always did his best to support his mum, who also has a learning disability. The brothers did everything together. The 31-year-old was autistic, and also had a learning disability and ADHD.
He had a great life, was a lifelong fan of Huddersfield Town Football Club and enjoyed discussing football. He was fond of his family, loved to treat them to meals
and buy small gifts, and enjoyed going on holiday with them, exploring new places. He gave the best hugs.
What happened
Scriven died from a pulmonary thromboembolism; this occurs when a blood clot forms and travels to the lungs and blocks the artery that carries blood from your heart. While serious, clots can be treated to stop people dying.
He first experienced a blood clot in August 2022. He went to hospital. Part of his treatment was to take an anticoagulant drug to prevent clots forming every day. He took his medication as prescribed.
In October 2022, Scriven had a cough and was breathless. He was seen in a vascular clinic and admitted to the hospital respiratory unit the following day. A scan showed a large blood clot was putting a strain on his heart.
A haematologist diagnosed that the medication was not working and needed changing. The respiratory consultant who was treating Scriven did not believe he was taking his medication regularly, and did not agree to change it. The young man was sent home without new medication.
He was discharged from hospital, and returned to have a scan of his heart carried out in November. The doctor who refused to change the medication said the scan results were not sent back to him. So there was no follow-up.
A discharge letter was sent by the hospital to the GP; one of the hospital consultants agreed with the coroner that this was “borderline useless” because it did not explain what had happened and information was inadequate or omitted.
In March 2023, Ashley contacted his GP surgery at 9am on a Thursday because his stepson
was breathless and had a cough. This information was passed to a GP at 2pm, but the family was not contacted.
The next day, Friday, Myles was phoned by a GP, who recorded in his notes that he “sounded OK on the phone”.
The following Monday, he was seen by a different GP because he was still feeling unwell. That GP said he examined the patient but his notes were incomplete. He made no diagnosis. He did not send him to hospital.
Less than a month, later an ambulance was called as Scriven was having trouble breathing. He collapsed and went into a cardiac arrest.
Although ambulance clinicians tried to restart his heart while they took him to hospital, he died in the accident and emergency department at Huddersfield Royal Infirmary on 16 April 2023.
The expert on learning disability and autism made a significant difference, enabling the court to understand what should have happened
Inquest
An inquest was opened nine months after the death. The final court hearings took place in May and June 2025, with assistant coroner Crispin Oliver delivering his conclusion in July.
This inquest was unusual because the coroner had three independent experts to give him advice. These were Professor Beverley Hunt, an expert on blood clots and bleeding, Dr Lynnette Hykin, an expert on GPs, and Dr Elizabeth Herrieven, an expert on learning disability and autism.
(Herrieven wrote for our spring issue this year on a toolkit to help emergency hospital staff to communicate with learning disabled people.)
Despite having reported from more than 30 inquests and seen more than 20 court–appointed experts give evidence over the past 10 years, I have never seen an expert in learning disability give evidence to the court before.
Expert input
The presence of an independent court expert on learning disability and autism made a significant difference, enabling the court to understand the impact on how Scriven was treated and what should have happened instead, from reasonable adjustments to accessible communication and the use of the Mental Capacity Act.
This was also the first inquest I have reported on where the coroner made a direct link between a lack of adjustments for someone’s learning disability and autism and their cause of death: “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.”
The coroner found the hospital care provided in October 2022 was neglectful. Staff knew their patient had a learning disability and was autistic (in part because an uncle had phoned them while on holiday to let them know). They also knew his medication was not working.
The GP said he examined the patient but his notes were incomplete. He made no diagnosis
The coroner found the death was preventable: “Myles’s needs were clearly apparent to those who could meet them. They could and should have been met in order to prevent his death. They were not.”
The coroner also found the actions of the GPs in March contributed to the death: “The GPs clearly only had a superficial grasp of the regulatory requirements and realities to do with learning disabilities.”
He found their communications to be “unsafe and unreliable”. They used learning difficulties and learning disabilities interchangeably and seemed to be ignorant as to the distinction between them and made only “modest adjustments for Myles”.
The coroner added that they “clearly had very little grasp of what the Learning Disabilities Register was and how it worked”.
The coroner issued two prevention of future deaths reports.
One was issued to the Dalton Surgery about the matters mentioned above and also the GP practice failing to undertake any rigorous or detailed internal learning review after the death.
The second was issued to Calderdale and Huddersfield NHS Foundation Trust.
The coroner said the trust was aware of the issues that arose in Scriven’s care, but he had concerns about how changes were made in practice.
“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… So, the question is – how it is proposed to ensure full compliance with best practice and by when?”
The family released a statement after the inquest.
They said: “Myles was systematically ignored and fundamentally failed by the very healthcare system designed to protect him.
“He was denied the most basic adjustments for his autism and learning disabilities, leading directly to catastrophic and incorrect decisions about his care and medication.
“The judgment makes it clear: no one saw Myles as an equal human being. The profound lack of insight shown by these institutions, both during his life and tragically, after his death, is simply unacceptable.”
Brendan Brown, chief executive of Calderdale and Huddersfield NHS Foundation Trust, said: “We accept the coroner’s findings in full, and will ensure these are used to build upon the changes made as a result of the trust’s internal review and the clinical lessons learned from Myles’ sad death.”
